Every finding on record at Southerncare, Inc.

Based on interviews and record reviews, the agency failed to ensure:1. Staff coordinated care to identify herbal supplements a patient was taking (Patient #2); and,2. Staff coordinated care to ensure supervision of a patient when provided care concerns were identified (Patient #2).This deficient practice was identified for 1 (Patient #2) of 3 sampled patients reviewed for coordination of services. Findings: --- Review of Patient #2’s Hospice Certification and Plan of Care for the certification period of 01/10/2026 through 04/09/2026 revealed Patient #2 was admitted to the agency on 01/10/2026 with diagnoses of in part, Secondary Malignant Neoplasm of an Unspecified Kidney and Renal Pelvis (kidney cancer), Pleural Effusion (condition which causes fluid of the lungs), and Hypokalemia (condition which causes low potassium of the blood). Review revealed Patient #2 was prescribed Tramadol 50 milligrams give 0.5 tablet every 6 hours and as needed. Further review revealed Patient #2 was to receive skilled nurse services once a week for one week; then twice a week for thirteen weeks.  1. Review of Patient #2’s Visit Note Report dated 01/10/2026 revealed Patient #2’s daughter informed S4Registered Nurse (RN) that she only used Chinese herbs and supplements because Patient #2 did not believe in taking prescribed medications.  In an interview on 03/18/2026 at 9:00AM, S4RN indicated Patient #2’s daughter was over protective and only wanted holistic medication. S4RN further indicated she (S4RN) was never able to clarify what supplements Patient #2 received. In an interview on 03/18/2026 at 11:09AM, S3RN indicated Patient #2’s daughter only wanted to doChinese herbs, and teas.  S3RN further indicated Patient #2 had some type of Chinese medications/herbs in the home, but the bottles were written in a different language.  S3RN further indicated the agency did not attempt to take any steps to find out what medication and/or herbs were in the bottles; therefore, the agency was unable to do an interaction check on the Chinese medication/herb and the medications in Patient #2’s emergency medication kit provided by the agency. S3RN indicated Patient #2’s daughter was unable to tell me what the name of the Chinese medication/herb she was giving, the time she was giving the medication/herb, or the amount given.   In an interview on 03/18/2026 at 2:00PM, S5Medical Director (MD) indicated he was aware Patient #2’s daughter did not want any type of prescribed medication other than Chinese medications/herbs, but all the directions were written in another language. S5MD further indicated there was a concern about the medication interacting with other medications; however Patient #2’s daughter did not administer her prescribed medication. S5MD further indicated Patient #2’s daughter was unable to translate any information for the agency staff regarding the Chinese medication/herb’s name.  In an interview on 03/18/2026 at 2:37PM, S1Administrator indicated the agency was aware of Patient #2’s daughter giving her mother Chinese medication/herbs, but the label was written in another language. S1Administrator further indicated the agency staff did not make any attempt to determine what the medications/herbs were. 2.Review of Patient #2’s Visit Note Report dated 01/13/2026 revealed, in part, S4RN made an as needed visit due to a report of Patient #2 having a fall with left arm injury.  Review of Patient #2’s Radiology Report dated 01/14/2026 revealed, in part, Patient #2 had a displaced angulated fracture to the left mid distal humerus (broken bone of the left lower arm).  Review of Patient #2’s Visit Note Report dated 01/19/2026 revealed, in part, Patient #2 was in her bed with no linen present, no clothing present to Patient #2, and Patient #2 had a soiled brief on. Further review revealed S3RN noted Patient #2’s dog had defecated and urinated on floor.  Further review revealed documentation of an observation of feces on Patient #2’s mattress, and there was no clean linens available to place on the bed. Further review revealed there was no working washer or dryer in the home; therefore the sheets were sent to the laundromat.  Further review revealed S3RN was aware Patient #2 was left alone when Patient #2’s daughter went to the store. S3RN notified the Medical Social Worker (MSW) of the need for caregiver assistance, and the need for increased hospice aide visits and volunteer visits.  Review of Patient #2’s record revealed no evidence of any hospice staff having made a home visit on 01/20/2026 to check on Patient #2’s safety.  Further review of Patient #2’s record revealed S6MSW did not complete a home visit after the above mentioned 01/19/2026 concerns were presented, until 01/26/2026.  Review of Patient #2’s Patient Information Report dated 01/24/2026 revealed, in part, Patient #2’s daughter called to inform the agency she had left Patient #2 home with a cell phone to go to the pharmacy, and Patient #2 called 911.  Further review revealed Patient #2 was being transported to a local hospital.  In an interview on 03/18/2026 at 1:41PM, S3RN indicated Patient #2’s daughter had left Patient #2 alone at times, and there were several times we would call to schedule a visit and Patient #2’s daughter would not answer the call, or the door. S3RN indicated Patient #2’s daughter would leave her alone for short periods to go to the store but she was informed Patient #2 was not to be left unattended.  S3RN further indicated on 01/19/2026, like most visits S3RN had to clean Patient #2. S3RN further indicated she had reached out to S6MSW for caregiver resources, and increased hospice aide services due to concerns, but did not have any documented evidence, nor could she remember what was done for Patient #2’s supervision on 01/20/2026.   In an interview on 03/18/2026 at 1:49PM, S6MSW indicated S3RN had reported to her on 01/19/2026 regarding Patient #2’s poor support system, and Patient #2’s daughter not fully understanding everything going on with Patient #2.  S6MSW further indicated she was made aware of concerns of Patient #2 having been left alone, with no supervision. S6MSW further indicated she did not have an answer for the reason as to why she did not complete a home visit on Patient #2 until 01/26/2026. In an interview on 03/18/2026 at 2:37PM, S1Administrator indicated based on the concerns identified by S3RN on 01/19/2026, she would have expected Patient #2 to have increased home visits to ensure Patient #2 was receiving appropriate care, and was not being left alone. S1Administrator further indicated she did not have an explanation for the reason why S6MSW did not make a home visit until 01/26/2026.

Upon observation, there was no evidence the agency has conducted exercises to test the emergency plan every two years. The agency was able to provide actual recorded events but no evidence of a second drill within the last two years.

Upon patient record review, 1 of 19 (Patient #9) did not have evidence that the patient chooses a health care provider, including an attending physician. Patient 9: The medical record contained an election form identifying the patient elected a community attending physician. There was no evidence of the agency utilizing the attending physician for medication and treatment orders after Oct of 2023, and the physician was changed in the profile to select the medical director as the attending physician with no change of physician form to document patient wishes.

Upon patient record review, 1 of 19 (Patient #4) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications. Patient 4: Upon home visit observation, the patient was receiving continuous tube feedings. There was no tube feeding formula type and administration rate included on the medication profile per agency expectations. Corrected on site.

Upon patient record review, 1 of 19 (Patient #3) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient 3: The medical record contained an initial bereavement assessment completed 2/5/24 with a start of care 1/26/24.

Upon patient record review, 2 of 19 (Patients #1,#4) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient 1: The medical record contained nursing documentation upon admission identifying patient issue with dysphagia requiring a modified diet. There was no evidence of problems, goals, and interventions related to dysphagia included in the plan of care. Corrected on site. Patient 4: The medical record contained nursing documentation upon admission identifying patient is a high fall risk. There was no evidence of problems, goals, and interventions related to fall safety included in the plan of care. Corrected on site.

Upon patient record review, 1 of 19 (Patient #4) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient 4: Upon home visit observation, the patient was receiving continuous tube feedings. There was no evidence of an order for tube feeding formula type and administration rate included in the plan of care. Corrected on site.

Upon patient record review, 6 of 19 (Patients #3,#6,#10,#11,#12,#14) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient 3: The medical record contains nursing documentation upon admission identifying patient use of a mechanical lift and bedside table. There was no evidence of orders for the equipment included in the plan of care. Corrected on site. Patient 6: Upon home visit observation, patient use of a cane was observed and discussed. There was no evidence of an order for the equipment included in the plan of care. Corrected on site. Patient 10: The medical record contains nursing documentation upon admission identifying patient use of a walker and wheelchair. There was no evidence of orders for the equipment included in the plan of care. Corrected on site. Patient 11: The medical record contains nursing documentation upon admission identifying patient use of a cane, walker, and wheelchair. There was no evidence of orders for the equipment included in the plan of care. Corrected on site. Patient 12: The medical record contains nursing documentation upon recertification 3/12/24 identifying patient use of a walker and wheelchair. There was no evidence of orders for the equipment included in the plan of care. Corrected on site. Patient 14: The medical record contains nursing documentation upon admission identifying patient use of a walker. There was no evidence of orders for the equipment included in the plan of care. Corrected on site.

Upon patient record review, 1 of 19 (Patient #7) did not have evidence that a revised plan of care includes information from the patient's updated comprehensive assessment and must note the patient's progress towards outcome/goals from the plan of care. Patient 7: The medical record contained nursing documentation upon recertification 2/15/24 identifying the patient's indwelling catheter was discontinued and removed in January. The plan of care still contained active problems, goals, and interventions related to catheter care. Corrected on site.

Upon client record review, 1 of 19 (Patient #7) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 7: The medical record contained an ordered nursing visit frequency of twice weekly. There was no evidence of a second visit completed the week of 3/17/24. Corrected on site with late entry documentation of a missed visit.

Upon patient record review, 1 of 19 (Patient #16) did not have evidence the hospice offers bereavement counseling that includes: • Making bereavement services available to the family and other individuals in the bereavement plan of care up to 1 year following the death of the patient. Bereavement counseling also extends to residents of a SNF/NF or ICF/IID when appropriate and identified in the bereavement plan of care • Ensuring that bereavement services reflect the needs of the bereaved Patient 16: There was no evidence the bereavement care plan tasks have been completed.

Upon patient record review, 1 of 19 (Patient #2) did not have evidence in the patient record that hospice aide assignments and duties are specific to the patient needs. Patient 2: The medical record contained nursing documentation upon admission identifying patient is a max assist for transfers. The aide care plan did not contain instructions on transfer assistance needed. Corrected on site.

Upon patient client record review, 2 of 19 (Patients #6,#12) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient 6: The medical record contained CTIs for benefit periods 1-5 identifying patient's primary diagnosis as Alzheimer's, benefit period identified diagnosis as failure to thrive, and benefit period 7 identified congestive heart failure. There was no evidence in the documentation to support the changes in diagnosis and the medical profile stated the primary diagnosis is hypertensive heart disease without heart failure supported by a change in diagnosis order 4/8/24. Patient 12: The medical record contained a CTI for benefit period 1 identifying patient's primary diagnosis of small bowel obstruction and benefit period 2 identified diagnosis of bowel cancer. There was no evidence in the documentation to support the change in diagnosis.

Upon client record review, 3 of 19 (Patients #3,#4,#5) did not have evidence that the hospice plan of care identifies the care and services that are needed and specifically identify which provider (nursing facility or hospice) is responsible for performing the respective functions that have been agreed upon and included in the hospice plan of care. Patient 3: The medical record contained a sacral wound order 4/25/24 that did not identify which provider is responsible for performing the wound care. Corrected on site. Patient 4: The medical record contained an initial plan of care order that did not identify which provider is responsible for performing the catheter changes and maintenance. Corrected on site. Patient 5: The medical record contained a sacral wound order 3/25/24 and 3/28/24 that did not identify which provider is responsible for performing the wound care. Corrected on site.

Upon patient record review, 1 of 19 (Patient #4) did not have evidence that the hospice provided the following information: • Hospice election form specific to each patient • Physician certification and recertification of the terminal illness specific to each patient • Names and contact information for hospice personnel involved in hospice care of each patient Patient 4: Upon home visit observation, there was no evidence of an election form or names of hospice personnel involved in care in the facility's hospice information.

Upon personnel record review, 1 of 12 (Personnel #11) did not have evidence the hospice obtained a criminal background check on all contracted individuals who have direct patient care and access to patient records. Personnel 11: There was no evidence of a criminal background check completed.